PAEDIATRIC OPHTHALMOLOGY AND STRABISMUS - SUBSPECIALTY CURRICULUM

PREAMBLE

COECSA Background

The College of Ophthalmology of Eastern Central and Southern Africa (COECSA) is a specialized virtual College founded in 2012 after a successful voluntary merger between the Eastern Africa College of Ophthalmologists (EACO) and Ophthalmological Society of Eastern Africa (OSEA).

The College seeks to work in tandem with regional and global initiatives and to support international commitments including Sustainable Development Goals (SDGs), WHO Vision2020: the Right to Sight; WHO AFRO Road Map for scaling up HRH; 4th EAC Development Strategy; national eye care plans in the region, and national development plans, towards Universal Health Coverage (UHC).

COECSA plays a critical role in the sector because of its mandate and available expertise in eye care at different levels. Its work augments what other partners are doing and provides a basis for further intervention in other areas that COECSA is not involved in. COECSA’s products such as research, curricula, standards, quality assessments, and policy reviews provide the basis to further programmatic intervention. COECSA, therefore, places premium on partnership and collaboration because it is the synergy that is brought by working with others that produces sustainable results. This is the reason why COECSA sees itself as a catalyst for action by many actors.

COECSA’s mandate is to: Support development of human resource for health through quality training in ophthalmology; set standards for professional ophthalmic practice; facilitate continuing professional development; contribute to health policy development; advocate for relevant policy changes in the region; promote research which advances ophthalmology in the region; and, create a forum for the ophthalmic practitioners to promote the profession and exchange skills and knowledge

Its Mission is: To improve the number and quality of eye care workers in Eastern, Central and Southern Africa through training, leadership and promoting standards of practice, research and advocacy.

The Vision is: Eye health for all in Eastern, Central and Southern Africa.

The Goal of COECSA is: Skilled and motivated eye health work force for quality eye care in Eastern Central &Southern Africa region.

Curriculum Model

The Fellowship in subspecialty curriculum is a hybrid model that promotes the following curriculum tenets:

• Integration (horizontal & vertical)
• Thematic/systematic Courses
• Small group learning methods
• Student-centred & Student-directed Learning
• Optimum use of IT learning technologies
• Primary care models (& health promotion approaches)

Curriculum Goal, Objectives and Outcomes

The Fellowship in subspecialty programmes provides essential intellectual and clinical information (i.e. cognitive and technical/surgical skills) that are necessary for ophthalmic personnel. The curriculum is a content outline for a fund of knowledge. It is not designed to be all-inclusive but rather a guideline for the subspecialty training.

Core Competences

Core competencies include:

• Patient Care
• Medical Knowledge
• Practice-based Learning and Improvement
• Communication Skills
• Professionalism
• Systems-based Practice

INTRODUCTION

Overview of Childhood Blindness

Childhood blindness refers to a group of diseases and conditions occurring in childhood or early adolescence, which, if left untreated, result in blindness or severe visual impairment that are likely to be untreatable later in life. Blindness in children can be defined as a visual acuity of <3/60 in the eye with better vision of a child under 16 years of age [1]. This generally means that the child cannot see something three feet (about one meter) away, that another child could see if it was 60 feet (about 20 meters) away [2]. The major causes of blindness in children vary widely from region to region, being largely determined by socioeconomic development, and the availability of primary health care and eye care services.

It is estimated that there are about 1.4 million blind children in the world and that about one child goes blind every minute. Three-quarters of the world’s blind children live in the poorest regions of Africa and Asia. Although there are fewer blind children than adults, the number of years lived with blindness is much higher for children. More than half of blindness in children is avoidable (either preventable or treatable); majority of the children who become blind have a lifetime of visual disability ahead of them with all the associated emotional, developmental impact onto the child’s life.

Definition of a Paediatric Ophthalmology and Rationale

A Paediatric Ophthalmologist is a. an ophthalmologist who has been trained on paediatric fellowship in a COECSA accredited or recognized centre, OR b. Any ophthalmologist trained outside of the COECSA accredited or recognized centres and underwent supervision by a COECSA Paediatric Ophthalmologist for at least 3 months in an accredited or recognized centre.

Paediatric ophthalmologists and strabismologists manage the entire spectrum of eye diseases. This may require collaboration with other medical and ophthalmic specialty areas.

The fellowship training is therefore focused on additional in-depth understanding and management of paediatric eye diseases and strabismus beyond that obtained in residency training. This training occurs during a continuous minimum period of 1 year and includes intense and focused training in developing and maintaining knowledge, skills, scholarship, and professionalism.

It is important that most eye problems presenting in childhood be corrected as early as feasible. Failure to correct these problems at an appropriate time early in life may result in permanent visual deficits, eye muscle disorders, and possibly legal blindness. This early attention to a child’s ocular problems should permit him/her to have optimal vision in adulthood.

The Paediatric Ophthalmology and Strabismus Subspecialty Curriculum wish to ensure that all future fellows are properly trained in Paediatric ophthalmology and strabismus by satisfactorily completing an appropriate post-residency fellowship training program.

Note that the curriculum guidelines have been categorised as:

• (M) Must have/required
• (S) Should have

STRUCTURE OF THE PROGRAMME

The overall goal is that the fellows will acquire surgical skills in the common surgical procedures used in pediatric ophthalmology and strabismus

Goal of the Paediatric Ophthalmology program

The goal of the pediatric ophthalmology program is to train the fellow to accurately diagnose and treat common and important pediatric eye diseases. Fellowship training in pediatric ophthalmology provides the fellow with the necessary knowledge and surgical skills to provide the patient with the highest quality medical and surgical care.

a) Subject Areas

i. Vision development in infancy and childhood [M]

ii. Ophthalmic examination in children [M]

iii. Neonatal ophthalmology, including retinopathy of prematurity [S]

iv. Refraction and amblyopia management [M]

v. Pediatric eye diseases, including uveitis, glaucoma, cataract, retinal diseases [S]

vi. Pediatric ocular tumors [S]

vii. Ocular manifestations of systemic diseases in children [S]

viii. Surgery, both primary and complex [S]

b) Pediatric Ophthalmology Knowledge and Diagnostic Skills Goals

i. To perform and interpret eye examinations for children, including visual acuity tests appropriate for the child’s age and condition. [M]

ii. To perform refraction in children, including retinoscopy.[M]

iii. To identify and manage amblyopia. [M]

iv. To participate in diagnosis and management of retinoblastoma. [S]

v. To be able to recognize and treat uveitis in children. [S]

vi. To be able to recognize and treat glaucoma in children by surgical and nonsurgical treatment. [S]

vii. To be able to recognize and treat cataract and lens subluxation in children by surgical and nonsurgical treatment. [S]

viii. To be able to recognize and treat retinal diseases in children by nonsurgical, laser, and surgical treatment. [S]

ix. To be able to recognize and treat retinopathy of prematurity. [M]

x. To be able to recognize and treat optic neuropathies.[S]

xi. To able to recognize and treat nystagmus in children. [S]

xii. To identify ocular and nonocular manifestations of systemic diseases with ocular involvement. [S]

c) Surgical Requirements for Pediatric Ophthalmologist-Based Fellowship

For a fellowship focused on pediatric ophthalmology, the fellow should perform at least 100 surgical procedures as primary surgeon. ii. At least 80 surgical procedures should be non-strabismus procedures in pediatric ophthalmology, and at least 20 surgical procedures should be strabismus procedures as primary surgeon. iii. A fellow cannot serve as both a primary surgeon and a first assistant for the same surgical case. iv. Examinations under anesthesia do not qualify as major cases.

Goal of the Strabismus Programme

The goal of the strabismus program is to train the pediatric ophthalmology fellow to accurately diagnose and treat all forms of adult and pediatric strabismus and ocular motility problems. Fellowship training in strabismus provides the fellow with the necessary knowledge and surgical skills to provide the patient with the highest quality medical and surgical care.

Strabismus Knowledge and Diagnostic Skills Goals

i. To describe and perform an accurate ocular motor and sensory examination––both basic and advanced––in pediatric and adult patients, including in patients who might be considered challenging (eg, uncooperative, cognitively impaired, nonverbal, preverbal). [M]

ii. To apply the most advanced knowledge of eye movement anatomy, neuroanatomy, and physiology to patient evaluation and surgical-decision making. [S]

iii. To describe clinical applications of basic and advanced sensory adaptations in strabismus patients. [S]

iv. To be able to recognize and treat any cause of esotropia. [M]

v. To be able to recognize and treat any cause of exotropia. [M]

vi. To be able to recognize and treat more complex strabismus patterns, such as restriction, paresis, and dissociated strabismus. [S]

vii. To be able to recognize and treat most complex etiologies of alphabet patterns and oblique muscle dysfunctions. [S]

viii. To be able to appropriately order and interpret testing such as orbital images (eg, CT and MRI) and Hess/Lancaster in the diagnosis, and medical and surgical management of the strabismus patient. [S]

ix. To be able to diagnose and correctly manage those strabismus patients in whom refraction management is indicated. [M]

x. To competently be able to perform retinoscopy in children. [M]

xi. To be able to perform successful Orthoptic assessments.

Surgical Requirements for Strabismus-Based Fellowships

1. a. For a fellowship focused on strabismus, it is recommended that the fellow perform at least 60 surgical procedures, of which 50 surgical procedures are strabismus procedures performed as the primary surgeon.
2. b. Being the primary surgeon means operating at least one complete muscle, under supervision.
3. c. A fellow cannot serve as both a primary surgeon and a first assistant for the same surgical case. Examinations under anesthesia do not qualify as major cases.

Strabismus Specific Surgical Goals

i. To understand and describe indications and contraindications for basic and more complex strabismus surgery. [S]

ii. To perform the preoperative assessment for patients undergoing extraocular muscle surgery, including measurement of strabismus angle in primary positions as well as the 9 cardinal positions of gaze and head tilts. [M]

iii. To know the indications for preoperative measurements in the various gaze positions. [S]

iv. To know the surgical anatomy, including muscle measurements, specific characteristics of the conjunctiva, subconjunctival fascia, individual muscles, and vascular supply in relation to extraocular muscle surgery. [M]

v. To know and be able to perform the basic surgical techniques involved in eye muscle surgery, including: setup, draping, prep and exposure, forced duction testing, incision options (and indications for the different incisions), and the principles of muscle dissection and suturing techniques. This would include proper instrument identification and choice and handling of instruments. [M]

vi. To know and be able to perform basic rectus muscle recession and resection procedures. [M]

vii. To know and be able to perform basic surgical procedures on the oblique muscles. This would include understanding of the indications for oblique muscle surgery and proper choice of available procedures. [S]

viii. To perform more complex extraocular muscle surgery, including reoperation, tuck, and transposition procedures. [S]

ix. To be able to manage postoperative complications for basic and more complicated strabismus surgery, such as a slipped muscle, globe perforation, endophthalmitis, anterior segment ischemia, and overcorrection. [S]

x. To understand the risks and benefits of adjustable suture surgery and to understand the techniques involved in adjustable suture surgery. [S]

xi. To have a working knowledge of the tables used for surgical numbers for eye muscle surgery. [S] xii. To assess the competency of the fellow using a measure such as the ICO-OSCARs. [S]

PROGRAM DELIVERY, CHARACTERISTICS AND TEACHING METHOD

The Paediatric Ophthalmology and Strabismus Fellowship must include lectures, conferences, or informal sessions at minimum in the following subject areas. Subject areas can be adapted to reflect local disease patterns and the particular needs of patients in the local area: [M]

Curriculum implementation shall be through apprenticeship, tutorials, log books, Workplace based assessments and any other method deemed appropriate

Program Qualifications

a) The training program must be based at an institution that is accredited by COECSA for paediatric ophthalmology fellowship training. This institution shall be known as the parent institution. [M] Where training is conducted in two training institutions: • the admitting institutions assumes full responsibility for the candidates training. This will include, but not limited to verification and documentation of such training undertaken at the partner institution. • If during the course of the training, any of the two institutions involved in the training decides to be accredited as a standalone training centre, a consideration will be made at the end of the training cycle.

b) The training institution should have a pediatric ophthalmologist with skills in strabismus surgery, as well as general pediatric surgeries e.g. congenital cataract. Where these are not available in the same center, the trainee will have to rotate to two or three accredited centers to complete the training requirements. [M]

c) It is desirable that the parent institution is associated with a general paediatric residency training program [S]

d) The number of fellowship positions approved must be determined based on the adequacy of clinical volume, number of faculty, and other resources, as determined by the fellowship director with the support and approval of the departmental chair. [S]

e) The fellowship program must receive approval/support confirmation from the chairman and/or program director of the parent institution. [S]

Program Compliance

All fellowship programs must comply with the requirements listed below. [M

a. Upon satisfactory completion of a fellowship training program, an individual will receive certification from COECSA and the training Institution. [M]

b. All fellowship programs are subject to periodic review to assure their continued compliance to the requirements listed below. [M]

c. Re-approval of a fellowship program is contingent upon having a fellow in training for at least one of the years covered by the triennial review. (A program that does not have a fellow for the three consecutive years of the triennial review period must reapply as a new program.) [M]

d. The implemented curriculum should comply with local and national regulations. [M]

e. Ethical Guidelines for Ophthalmologists: Ethical Principles and Professional Standards should also be practiced in the program. Each of the nine standards that follow includes a general principle from which the related standards evolve. The standards taken together are intended to represent comprehensive guidelines to reflect the ideals to which ophthalmologists should aspire as members of a specialist branch of the medical profession, and as socially responsible members of their respective professional societies. [S]. Below are the ethical Standards:

• Patient Care Standards
• Professional Practice Standards
• Professional Community Standards
• Standards for Working with Other Health Care Professionals
• Research Standards
• Social Standards
• Commercial Standards
• Teaching and Mentorship Standards
• Standards Governing the Relationship to the Medical Industry

Programme Characteristics

a. Medical liability coverage must be provided to the fellow by the program or applicant during his/her training (unless provision of such coverage is in conflict with institutional policies or local statutes). [M]

b. The medical and surgical care provided by the fellow during his/her training must be supervised. [M]

c. A journal club specific to the paediatric ophthalmology/strabismus program must be held at least six times per annum. [S]

d. The fellow should have ready access to a major medical library and facilities for electronic retrieval of information from medical journals and databases. [S]

e. The fellow is required to prepare and present teaching conferences and participate in the teaching of residents and/or medical students. [M]

f. The fellow should be involved in the ongoing research activities of the department. [S]

g. The teaching program must include:

• An ongoing program of study of the pertinent literature, guided by the faculty. [M]
• Informal and formal didactic teaching, as well as access to pertinent reading materials. [M]
• The provision of appropriate clinical material (i.e. patients for examination, evaluation, treatment, and discussion). [M]

ADMISSION REQUIREMENTS

In order for a consideration to be made for admission to this fellowship, the applicant must; i. Have satisfactorily completed a residency program in ophthalmology, and must be a COECSA fellow or possess its equivalence. NOTE: o The fellowship is primarily only open to COECSA fellows (1st Priority). Fellows will be admitted at a subsidized rate. o Second option is members of COECSA in good standing – These will be admitted at a Higher Fee agreed on in liaison with the Executive Committee. o Third option – Licensed, Qualified Ophthalmologists outside the region at a Much Higher Fee as agreed on in liaison with the executive committee ii. Possesses at least two years experience in active ophthalmology practice and must have performed at least 200 cataract surgeries independently. iii. The fellow must be able to fully comply with the clinical requirements of the program. iv. Prior to entry into the program, each fellow will be given an orientation period for familiarization with the institute, the clinic, and the basic examination skills. Each fellow is required to be notified of the required length of the program, policies for vacation, duties, stipends, and other forms of support.

SELECTION PROCESS

All applications shall be reviewed by a selection panel from COECSA and the training institutions. The panel will consist of:

1. The COECSA Education & Accreditation Committee,
2. Paediatric Ophthalmology and Strabismus Specialists, and
3. COECSA Education and Training Officer (ex-officio)

COURSE DURATION

A minimum of 12 months (not necessarily consecutive) of clinical training is required, with vacation time and sick/personal leave at the discretion of the program director, and not exceeding two (2) weeks. Extension of the training period greater than 3 months, or an extended leave of absence, should have prior approval. A 24-month training program with 50% of the fellow’s time in fellowship training can also be considered. [M]

• At least 50% (6 months) of the fellow’s time must be spent at the parent institution or at one of the hospitals or sites that are part of the parent institution. [S]
• If part of the 12 months of training is spent away from the parent institution, verification and documentation of such training is the responsibility of the program director. [S]
• Where training is conducted at two training institutions, the admitting institution assumes full responsibility for the candidates training. This will include, but not limited to verification and documentation of such training undertaken at the partner institution.
• If during the course of the training, any of the two institutions involved in the training decides to be accredited as a standalone training centre, a consideration will be made at the end of the training cycle
• During the time of accreditation and commencement of the COECSA Subspecialty Fellowship program, there may be candidates already in training, admitted by the institution.
• At the accreditation stage: The training institution will submit names of candidates in training.

The candidates will then be assessed against COECSA’s admission and exit criteria to ascertain if they meet the minimum requirements for a COECSA fellowship/specialist qualification.

FACULTY/TRAINER QUALIFICATIONS AND RESPONSIBILITIES

Generally, the Faculty/Trainers need to be in the register of COECSA Faculty; Must be approved by paediatric community of practice, and have completed Train the Trainers and training in examination.

Fellowship Program Director

There must be a single program director responsible for the fellowship program. [M]

Qualifications of the fellowship program director:

1. Required to possess appropriate educational qualifications, including certification in ophthalmology and paediatric/strabismus-fellowship training. [M]
2. Required to have at least 3 years of clinical experience in paediatric ophthalmology and strabismus following his/her fellowship training. [M]
3. Required to have undergone COECSA training of trainers’ course. Note: In rare circumstances, in regions where there may not be a fellowship-trained program director, a senior ophthalmologist may have 10 or more years experience in substantial (greater than 50%) paediatric/strabismus practice, including contribution to the literature in the way of clinical or basic research. Such a clinician should be considered an appropriate primary supervisor.
4. Should be engaged in ongoing basic and/or clinical science research in the area of pediatrics/strabismus, as demonstrated by regular publications in peer-reviewed journals and/or presentation of research material at national and international meetings. [S]
5. Required to have a clinical practice with at least 50% of patients who have pediatric/strabismus-related disorders. [M]
6. Required to have an academic appointment on the faculty of the affiliated ophthalmology-residency program or affiliated institution. [M]
7. Required to be licensed to practice medicine in the state or country where the institution that sponsors the program is located. [M]

Responsibilities of the fellowship program director:

a. Required to design and supervise the educational experience. [M]

b. Required to prepare a written statement outlining the educational goals of the program with respect to knowledge, skills and other attributes, and educational goals for each major rotation or other program assignments. [M]

c. Should promote awareness of the fellowship opportunity by providing a job description and requesting applications via a public website. [S]

d. Required to develop and maintain documentation of institutional or inter-institutional agreements, the fellowship selection process, patient-care statistics, evaluations of faculty and the program, and assessment of the fellows’ performance. [M] e. Required to select fellows in accordance with institutional and departmental policies and procedures. [M]

f. Required to designate and supervise the faculty through explicit descriptions of supervisory lines of responsibility for the care of patients. [M]

g. Required to ensure the implementation of fair procedures and due process regarding academic discipline and fellow complaints or grievances, as established by the sponsoring institution. [M]

h. Required to keep open lines of communication with their fellows and be sensitive to issues of professional and personal stress, which may interfere with the fellows’ interaction with patients and colleagues, both medical and non-medical. The fellowship program director should be aware of issues that would interfere with the professional development of their fellows and be willing to facilitate timely provision of confidential professional counselling and psychological support services to fellows. Training situations that consistently produce undesirable stress on fellows must be evaluated and modified. [M]

i. Required to ensure that accurate statistical and narrative descriptions of the program are developed and maintained. [M] j. Any change in the fellowship director position is to be communicated within 90 days. [M]

Duties of the fellowship program director:

a. Maintain an active clinical service in paediatric ophthalmology and/or strabismus at the parent institution. [M]

b. Periodically (at least once every 6 months) assess the fellows by means of adequate documentation and make adjustments for areas of deficiency. [M]

c. Personally, supervise the administration and implementation of fellowship requirements. [M]

d. Certify the satisfactory completion of the course of training by the fellow at the end of the training program. [M]

e. Engage in ongoing research in the field of paediatric ophthalmology and/or demonstrate regular publications in peer-reviewed journals and/or presentation of research material at national meetings, and/or appointments to national or international committees in this specialty. [S]

Faculty in Paediatrics/Strabismus

It is required that there be at least one faculty member who is the fellowship program director. [M] Additional supervising faculty for each approved fellowship position is desirable. [S]

Qualifications of the faculty:

a. The primary faculty of the fellowship program must be a trained paediatric ophthalmologist and/or strabismologist. The fellowship program director must have had at least three years of clinical experience following his/her training, and hold a current appointment in the ophthalmology department of the parent institution. In addition, to serve as the program director, the faculty member must have been at the site of that program for at least two years, unless there is a current fellowship in place, in which case they can assume directorship immediately. [M]

b. Must be a COECSA fellow in paediatric ophthalmology and strabismus, or from a recognized institution.

c. In addition to working with the program director, the fellow(s) should have the opportunity to work at least 20% of the time (eg, one day/week) with the other faculty members in the program and this should be reflected in the weekly/monthly schedule. [S]

Responsibilities of the faculty:

a. Be highly qualified and possess appropriate clinical and teaching skills. [M]

b. Devote adequate time to the education of fellows. [M]

c. Demonstrate a strong interest in the education of fellows, have sound clinical and teaching abilities, support the goals and objectives of the program, and be committed to their own continuing medical education and participation in scholarly activities. [M]

d. Maintain regularly scheduled, documented meetings in order to review the program’s goals and objectives, as well as the program’s effectiveness in achieving goals and objectives. [M]

e. Periodically evaluate the utilization of resources available to the program, the contribution of each institution participating in the program, the program’s financial and administrative support, the volume and variety of patients available for educational purposes, the performance of faculty members, and the quality of supervision of fellows. [M]

f. Periodically evaluate outcomes of the research activities of the fellows. [M]

g. Evaluate curriculum and career development of the fellows. [M]

h. Each faculty member must have paediatric/strabismus subspecialty fellowship training or equivalent training and be a member of the faculty of the sponsoring institution. In addition, research faculty and scientists may be involved with the clinical fellowship program and are encouraged to interact with the fellows. [M]

Other Program Personnel

Programs must be provided with the additional professional, technical, and clerical personnel needed to support the administrative and educational activities of the program. [M]

TRAINING ASSESSMENT, EVALUATION& QUALIFICATION

Documentation and verification of the program’s activities is required annually and must include the following: i. A surgical log must be kept by the fellow and reviewed by the program director. The director must keep a summary of the fellow’s surgical experience over the one-year training period. The log must include diagnosis, surgery performed, outcome, and whether the fellow is first assistant or primary surgeon. [M] ii. A list of conferences/lectures given by the fellow. [M] iii. A list of journal club subjects evaluated by the fellow. [M] iv. A list of submitted/published papers and papers/research projects presented at national meetings by members of the department, including fellows. [M] v. Maintain regularly scheduled, documented meetings in order to review the program’s goals and objectives, as well as the program’s effectiveness in achieving its goals and objectives. [M] vi. The program director must provide a written, final evaluation for each fellow who completes the program. The evaluation must include a review of the fellow’s performance during the period of training and should verify that the fellow has demonstrated sufficient professional ability to practice competently and independently. This final evaluation must be part of the fellow’s permanent record maintained by the institution. [M] vii. Fellows compliance to the program and submission of an exit survey are program requirements. [M] viii. Should produce at least one publishable research during the training.

(See appendix C: Detailed Training Evaluation Forms)

EXIT CRITERIA

This shall take three stages:

• Stage 1: Final Training Evaluation by the Training Institution, who will make recommendation to the COECSA subspecialty panel
• Stage 2: Evaluation by the COECSA subspecialty selection panel, who will make recommendation to the College Senate
• Stage 3: Validation and Approval by the College Senate

CERTIFICATION AND TITLE OF FELLOW

Certification will be done by COECSA in conjunction with the training institution, after the exit process has been thoroughly completed. • Title to be awarded after completion of the training is: Paediatrics & Strabismus Specialist (COECSA)

UNSUCCESSFUL TRAINEE

In the event that a trainee does not meet the minimum requirements provided above; a) There will be an extension of the training by 3 months in order to meet the requirements. b) In the event that after the 3 months extension the candidate does not meet the above minimum requirements, training will discontinue.

INSTITUTION FACILITIES AND RESOURCES (GUIDELINES)

Institution Organisation

a.If the Fellowship program in pediatric ophthalmology and strabismus is also in an institution that sponsor residency programs in ophthalmology, there should be coordination of the fellowship and residency programs, so that both benefit. While affiliation of the fellowship and residency programs may not be required, it is recommended. [S]

b.The institution committed to offering a pediatric ophthalmology and strabismus fellowship program should have the capacity––and appropriate infrastructure––for high quality, diverse exposure to complex pediatric ophthalmology and strabismus cases and their management. Educational activities, including didactic lectures and grand rounds, are necessary. Research activities, including presentations at meetings, are part of the pediatric ophthalmology and strabismus fellowship program and fellows are encouraged to participate in such activities. [S]

c.The number of fellowship positions approved will depend on the adequacy of clinical volume, number of faculty, and other resources, as determined by the fellowship director with the support and approval of the departmental chair. [S]

d.The fellowship program should receive a letter of support from the chairman and/or program director of the parent department of ophthalmology. The fellowship program, as much as possible, should complement, support, and enhance the residency program. The department chair, fellowship program director, and residency program director should work together and periodically meet to assure that the presence of the subspecialty fellowship does not unduly draw cases, learning opportunities, or funding from the residency program. [S]

Facilities and Resources

Clinic

The outpatient area of each participating institution must have a minimum number of fully equipped examination lanes for each fellow in the clinic. There must be access to current diagnostic equipment. [M]

The following are the recommended equipment requirements for the outpatient clinic:

i)Direct and Indirect ophthalmoscopes

ii)Lenses +20D, +90D and +75D.

iii)Torch

iv)Tonometers; i-care, Sciotz, Tonopen, Perkins or Air puff.

v) Slit lamps- Portable or stand

vi) Vision Charts:- Snellen, E, Pictoral

vii) Refraction set +Retinoscope

viii) Autorefractor

ix) Prisms

x) Patches/Occluders

xi) Eyedrops/Diagnostics: - Amethocaine, Mydriatics, Atropine and Flourescein strips/drops

Fellows are encouraged to have the following as their personal equipment:

i) Ophthalmoscopes; Direct and Indirect

ii) Retinoscope

iii) Prisms and Occluders

iv) Lenses; +20D, +90D and/or+78D

Operating Facilities

There must be adequate operating facilities, including an operating microscope to perform and teach surgeries. [M]

The following are the recommended basic requirements for theatre:

i) Operating microscope

ii) Vitrector- Vitron 2020 etc

iii) IOLs

iv) Viscoelastics

v) Knives: - Keratomes, Crescent and MVR

vi) Cryo

vii) Laser

iii) Implants

ix) Sutures

x) Lacrimal(probing and syringing)

xi) Cataract sets

xii) Portable hand held keratometer

xiii) B-, and A-Scan for biometry

Inpatient Facilities

There must be inpatient facilities with access to sufficient space and beds for good patient care. [M]

Library/Internet services

Fellows must have ready access to a major medical library and facilities for electronic retrieval of information from medical databases. [M]

(See appendix D: Detailed institution accreditation guidelines)

1.     PROGRAM SUMMARY

(Theory courses 15 lecture Hours=1Credit Unit; Clinical/Practical/Surgical courses 45 Clinical Hours=1CU; Research, 30 Research Hours=1CU)

Course Code	Title	Lecture/ Tutorial Hours	Practical/ Clinicall Hours	Surgical Hours	Credit Unit
POS1	Vision development in infancy and childhood	7.5	11.25	0	0.75
POS2	Embryological basis of conditions relative to pediatric ophthalmology	7.5	11.25	0	0.75
POS3	Neonatal ophthalmology,particularly retinopathy of prematurity	7.5	11.25	22.5	1.25
POS4	Genetics, inborn errors of metabolism, and syndromes involving the eye	7.5	11.25	0	0.75
POS5	Ocular manifestations of systemic disease in children	7.5	11.25	11.25	1.0
POS6	Vision and learning; dyslexia	7.5	11.25	0	0.75
POS7	Vision screening	7.5	22.5	0	1.0
POS8	Treating the visually handicapped child; low-vision management	7.5	45	0	1.5
POS9	Pediatric ocular trauma	7.5	11.25	22.5	1.25
POS10	Pediatric ocular tumors	7.5	11.25	22.5	1.25
POS11	External ocular disease	7.5	11.25	22.5	1.25
POS12	Lacrimal disorders	7.5	11.25	22.5	1.25
POS13	Lid disorders	7.5	11.25	22.5	1.25
POS14	Corneal disorders	7.5	11.25	22.5	1.25
POS15	Uveal disorders	7.5	11.25	0	0.75
POS16	Lens disorders	7.5	45	45	2.5
POS17	Pediatric glaucoma; primary and secondary	7.5	22.5	22.5	1.5
POS18	Retina and vitreous	7.5	22.5	22.5	1.5
POS19	Neuro-ophthalmology	7.5	11.25	0	0.75
POS20	Electrodiagnostic testing	7.5	11.25	0	0.75
POS21	Ultrasound, computerized tomography (CT) scan, and magnetic resonances imaging (MRI) in pediatric ophthalmology	7.5	22.5	0	0.75
POS22	Ethical considerations specific to pediatric ophthalmology	7.5	11.25	0	0.75
POS23	STRABISMUS Anatomy, physiology, neuroanatomy	7.5	11.25	0	0.75
POS24	Sensory adaptation and testing	7.5	11.25	0	0.75
POS25	Amblyopia diagnosis and treatment	7.5	22.5	0	1.0
POS26	Optics and Clinical refraction	7.5	22.5	0	1.0
POS27	Esodeviations and Exodeviations	7.5	45	45	2.5
POS28	Vertical and incomitant strabismus	7.5	22.5	22.5	1.5
POS29	Ophthalmoplegic syndromes	7.5	11.25	11.25	1.0
POS30	Nystagmus	7.5	11.25	0	0.75
POS31	Research project	7.5	60	0	2.5

Surgical Outline Syllabus

Serial number	Name of procedure		Minimum number of cases
1	Lens procedures (ECCE, anterior vitrectomy, ECCE with IOL)		50
2	Glaucoma (goniotomy, trabeculotomy, trabeculectomy cryo application etc.)		10
3	Horizontal squint (different techniques)		20
4	Retinoblastoma (Including salvage therapy, laser and cryotherapy, chemotherapy)		20
5	Oculoplasty (lids and orbit)		10
6	Lacrimal procedures (Probing & syringing +/- DCR)		10
7	Anterior Vitrectomy		30
8	Yag and Diode laser		30
9	Eye removals (enucleation, evisceration) exenteration)		20
10	Refraction (30 retinoscopy, 20 subjective)		30
11.	RoP screened and treated		20

(See Appendix E: Detailed Syllabus)

2.    TRAINING COSTS

A breakdown of the training costs for the Paediatrics and Strabismus Fellowship has been developed based on prevailing rates supplied by some training institutions in the region. (see appendix B: Paediatrics and Strabismus Fellowship Training costs)

3.     APPENDIX

i.                   Appendix A: Acknowledgement

The College of Ophthalmology of Eastern, Central &Southern Africa (COECSA) leadership wishes to acknowledge the Education &Accreditation Committee for providing leadership in the overall development of the subspecialty training curriculum.

The curriculum has been developed through a participatory and consultative environment with significant contributions and support from various individuals and institutions. I therefore wish to extend my sincere appreciation to all those that contributed to the process of developing this curriculum.

I wish to pay special tribute to Dr. John Onyango, the Chair of the Pediatrics Ophthalmology and Strabismus curriculum subcommittee for the significant input and commitment to this process. I also acknowledge the tremendous contributions of the members of the subcommittee, in particular I wish to thank the following:

Dr. Ibrahim Matende

Dr. Lucy Njambi

Dr. Kahaki Kimani

Dr. FurahiniMdeme

Dr. Sarah Sitati

Dr. Gerald Msukwa

Dr. Muma Mulenga

Dr. Willard BwalyaMumbi

Dr. Grace Ssali

The College extends special gratitude to the Commonwealth Eye Health Consortium (CEHC) for providing funding through the London School of Hygiene and Tropical Medicine (LSHTM), International Centre for Eye Health (ICEH) that made this process possible. We are particularly grateful to Ms. Sally Gillespie and Dr John Buchan of LSHTM for their unrelenting support.

Last but not least, we would like to acknowledge the secretarial and logistical support of the COECSA secretariat.

Yours Sincerely,

Dr. John Nkurikiye

President - COECSA

3^rd March, 2020

iii.              Appendix C: Training Assessment Tools and Portfolio

EVALUATION LOG BOOK

FOR SUB-SPECIALTY FELLOWSHIP IN PEDIATRIC OPHTHALMOLOGY AND STRABISMUS

NAME: _____________________________________

FELLOWSHIP CENTER: ______________________

YEAR: _____________________________________

A.   CHAPTER ONE: HISTORY TAKING AND EXAMINATION

1. CASE PRESENTATION: PEDIATRIC VISUAL ACUITY

(Lea’s/ Logmar or other Pictorial tests, Lea’s gratings, Cardiff, Tumbling Es, etc)

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

1. CASE PRESENTATION: ORTHOPTIC ASSESSMENT

(CT/ UCT, PCT, Krimsky test, EOMM)

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

3.     CASE PRESENTATION: PEDIATRIC TUMORS

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

1. CASE PRESENTATION: PEDIATRIC OCULAR TRAUMA

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

1. CASE PRESENTATION: PEDIATRIC CATARACT (Congenital, Developmental, Traumatic)

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

1. CASE PRESENTATION: PEDIATRIC GLAUCOMA (Congenital, Juvenile idiopathic)

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

1. CASE PRESENTATION: LID AND ADNEXAE DISEASES (e.g lid colobomas, lid masses, distichiasis, dermoid cysts, etc)

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

1. CASE PRESENTATION: IMAGING INTERPRETATION AND ULTRASOUND

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

B.   CHAPTER TWO: SURGICAL TECHNIQUES

1. PEDIATRIC CATARACT (MINIMUM 3Congenital, 3 Developmental, 3 Traumatic)

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

1. HORIZONTAL STRABISMUS:

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

1. COMPLICATED STRABISMUS (Vertical, Oblique muscles, Repeat surgeries, Transpositions, etc)

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

1. PEDIATRIC OCULAR TRAUMA

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

1. PEDIATRIC TUMORS (MINIMUM 5Retinoblastoma)

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

1. PEDIATRIC GLAUCOMA (Congenital, Juvenile, secondary)

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

1. PEDIATRIC ANDEXA AND LID SURGERIES

DATE	PATIENT NAME& IP NO	DIAGNOSIS	SUPERVISORS NAME	SIGN

C.     FELLOWSHIP FACULTY EVALUATION FORM

Name of Faculty Member:           

Evaluation Period (provide start & end dates): 

Name of Fellow:

Informal Teaching

	N/A	Lowest 1	2	3	4	Highest 5
Shows me interesting patients
Discusses interesting patients and problems
Is available to supervise fellow for clinical work
Shows interest in clinical opinion of fellow
Delegates responsibility well to fellow in clinic
Provides appropriate supervision in clinic
Delegates responsibility to fellow in surgery
Provides appropriate supervision and advice during surgery

Formal Teaching

	N/A	Lowest 1	2	3	4	Highest 5
Is punctual and dependable  in  Conferences
Seminars are organized and logical
Invites fellow discussion and questions
Shows enthusiasm in teaching fellows
Demonstrates a keen interest in improving teaching sessions
Overall quality of seminars/teaching sessions

Interaction with Fellow

	N/A	Lowest 1	2	3	4	Highest 5
Offers timely feedback in an appropriate setting
Provides positive reinforcement when appropriate
Stimulates independent study/inquiry
Teaches a logical approach to problem solving
Stimulates research questions
Provides appropriate support for research project(s)
Freely admits when he/she does not know something
Offers and receives advice gracefully
Overall availability
Overall dependability
Is an effective role model for fellow

Overall Assessment

	N/A	Lowest 1	2	3	4	Highest 5
Overall assessment

Please specify at least three things that this teacher did well: 

Please specify what this faculty member could do differently to improve their effectiveness as a teacher: 

Any other constructive comments:

Thank you very much for taking the time to complete this form.

1. FELLOW EVALUATION OF FELLOWSHIP PROGRAM

We appreciate it very much if you could please complete the following questions in order that we may be able to continuously improve the fellowship program experience in our Department.

1. What two or three things did you feel went especially well from a logistics/process perspective?

2. What two or three things could be improved to provide better support for future fellows?

3.  Did you receive notification of grand rounds, Journal Clubs and other academic activities?  If so did you feel that these added value to your experience?

4.  Was informal feedback provided to you by your preceptor(s) on an ongoing basis and could anything be done to improve this?

5. Were you provided with a formal evaluation via your primary preceptor and/or subspecialty fellowship director? Did you have the opportunity to discuss the evaluation in person with this individual?

6.  How would you rate your educational experience overall?  What could be done to enhance the educational experience for future fellows?

7.  Did you feel that there was a balanced distribution of learning opportunities in the clinic/OR between fellow and resident(s)? If not, what could be done differently to improve your learning opportunities?

8.  Did you have the opportunity to participate in a research project?  If so how did this experience turn out?  Any plans for presentations/publications?

8. Was the administrative support during your fellowship adequate?  If not, what could be done to provide additional support?

iv.              Appendix D: Institution Accreditation Guidelines and Self Evaluation Form

A.     ACCREDITATION PROCESS

The following process apply to the COECSA accreditation process:

1)     STEP 1: Application for Accreditation

·        Institution express interest for accreditation in writing to the Secretariat

·        Application/Accreditation pack will be made available which will include the Self-Assessment Form, Detailed relevant curriculum and this application form.

·        The completed file/forms must be returned to COECSA Secretariat. If COECSA does not receive the completed application pack within a month, it is assumed that there is no longer interest in continuing the process.

·        NOTE: The application will only be considered valid if the following documents have been attached:

ü  Completed Application Form

ü  Registration Certificate/s

ü  Completed Self-Assessment Form

ü  Partnership Agreement/s (where two or more institutions are collaborating)

2)     STEP 2: Desk Review

·        The application is reviewed by the College Education & Accreditation Committee

·        The applicant will then be informed of the committees findings.

·        If the preliminary findings do not meet accreditation standards, the applicant can take remedial action within months, and continue with the same application. However, if remedial action is not completed within this period, a fresh application will have to be started.

·        If preliminary findings meet the threshold for accreditation, an agreement will be reached with the applicant on the dates for site visits by the accreditation team.

3)     STEP 3: Site Evaluation Visit

·        COECSA appoints an appropriate accreditation team.

·        The Accreditation Team conducts on-site assessment

·        Evaluation report is drafted by the Chairperson of the Team

·        Report is submitted to the Education & Accreditation Committee

4)     STEP 4: Accreditation and Certification

·        Accreditation Report is submitted to the Senate by the Education & Accreditation Committee chairperson.

·        The final outcome including recommendations are communicated to the applicant

·        Unfavorable applicants can reapply for a second site visit. This reapplication must be accompanied with details of how compliance recommendations have been addressed.

·        Should the evaluation results be favorable, the institution will be granted a provisional COECSA accreditation valid for 18 months. If during its validity, no trainee is enrolled, then the accreditation process will have to be restarted.

·        The full COECSA accreditation certificate valid for 3 years, will only be granted following assessment 1 year after commencement of training.

B.     APPLICATION FORM

APPLICATION FORM

Accreditation as COECSA Subspecialty Training Institution

Subspecialty for which this application is made: ………………………………………………….

SECTION A: Applicant Information

Legal Name
Trade Name
Type of Institution
Location
Registration Status/Number
Annual Budget
Short Description (Vision, Mission, Goals, Principles)

Postal Address
Postal Code
Physical Address
Code
Phone Number/s
Fax Number
Province/District/County

Contact Person Name
Phone Number
Cell Phone Number
Email Address
Signature/Date

SECTION B: Applicant Host Institution

Legal Name
Trade Name
Type of Institution
Location
Registration Status/Number
Short Description (Vision, Mission, Goals, Principles)

Postal Address
Postal Code
Physical Address
Code
Phone Number/s
Fax Number
Province/District/County

Contact Person Name
Phone Number
Cell Phone Number
Email Address
Signature/Date

SECTION C: Collaborating Institution/s (Where the training will be offered in two collaborating institutions, the applicant must provide details of collaborators. This must be supported by an agreement clearly outlining the roles and responsibilities of each partner institution)

Legal Name
Trade Name
Type of Institution
Location
Registration Status/Number
Short Description (Vision, Mission, Goals, Principles)

Postal Address
Postal Code
Physical Address
Code
Phone Number/s
Fax Number
Province/District/County

Contact Person Name
Phone Number
Cell Phone Number
Email Address
Signature/Date

SECTION D: Declaration by Host Institution (where the applicant is a department or section under a main institution. The purpose is to ensure that the applicant has the full support/approval of the host institution to run the training programme.)

We …………………………….. (name of host institution) hereby declare that we have approved and fully support the decision by ………………………… (name of applicant) to seek COECSA accreditation for the ………………………………… (title of supspecialty) subspecialty fellowship programme. We will provide full support during the accreditation process, and in implementing the programme thereafter.

…………………………………………..                       -------------------------------------  ………………………….

Name of Authorized Person                                    Signature                                Date

Thank you for your interest in partnering with COECSA.

END.

C.      ASSESSMENT GUIDELINES – Institution Organisation

o  If the Fellowship program in pediatric ophthalmology and strabismus is also in an institution that sponsor residency programs in ophthalmology, there should be coordination of the fellowship and residency programs, so that both benefit. While affiliation of the fellowship and residency programs may not be required, it is recommended. [S]

o  The institution committed to offering a pediatric ophthalmology and strabismus fellowship program should have the capacity––and appropriate infrastructure––for high quality, diverse exposure to complex pediatric ophthalmology and strabismus cases and their management. Educational activities, including didactic lectures and grand rounds, are necessary. Research activities, including presentations at meetings, are part of the pediatric ophthalmology and strabismus fellowship program and fellows are encouraged to participate in such activities.[S]

o  The number of fellowship positions approved will depend on the adequacy of clinical volume, number of faculty, and other resources, as determined by the fellowship director with the support and approval of the departmental chair.[S]

o  The fellowship program should receive approval/support from the chairman and/or program director of the parent department of ophthalmology. The fellowship program, as much as possible, should complement, support, and enhance the residency program. The department chair, fellowship program director, and residency program director should work together and periodically meet to assure that the presence of the subspecialty fellowship does not unduly draw cases, learning opportunities, or funding from the residency program.[S]

D.     ASSESSMENT GUIDELINES: Facilities and Resources

i)                 Clinic

The outpatient area of each participating institution must have a minimum number of fully equipped examination lanes for each fellow in the clinic. There must be access to current diagnostic equipment. [M]

The following are the recommended equipment requirements for the outpatient clinic:

§  Direct and Indirect ophthalmoscopes

§  Lenses +20D, +90D and +75D.

§  Torch

§  Tonometers; i-care, Sciotz, Tonopen, Perkins or Air puff.

§  Slit lamps- Portable or stand

§  Vision Charts:- Snellen, E, Pictoral

§  Refraction set +Retinoscope

§  Autorefractor

§  Prisms

§  Patches/Occluders

§  Eyedrops/Diagnostics:- Amethocaine, Mydriatics, Atropine and Flourescein strips/drops

Fellows are encouraged to have the following as their personal equipment:

§  Ophthalmoscopes; Direct and Indirect

§  Retinoscope

§  Prisms and Occluders

§  Lenses; +20D, +90D and +78D

ii)               Operating Facilities

There must be adequate operating facilities, including an operating microscope to perform and teach surgeries. [M]

The following are the recommended basic requirements for theatre:

§  Operating microscope

§  Vitrector- Vitron 2020 etc

§  IOLs

§  Viscoelastics

§  Knives:- Keratomes, Crescent and MVR

§  Cryo

§  Laser

§  Implants

§  Sutures

§  Lacrimal(probing and syringing)

§  Cataract sets

§  Portable hand held keratometer

§  B-, and A-Scan for biometry

iii)            Inpatient Facilities

There must be inpatient facilities with access to sufficient space and beds for good patient care. [M]

iv)             Library/Internet services

Fellows must have ready access to a major medical library and facilities for electronic retrieval of information from medical databases. [M]

E.      INSTITUTION SELF-EVALUATION FORM

NAME OF INTITUTION: ……………………………………………………    CITY: …………………………………………     COUNTRY: ………………………………..

REPORT COMPLETED BY: (Name and Signature): ……………………………………………  TITLE: ………………………………… DATE: ………………..

ASSESSMENT AREA/ QUALITY INDICATOR	GUIDELINES/ PREFERRED PRACTICE	STATUS: A = AVAILABLE/Yes N = NOT AVAILABLE/No	COMMENTS
a)   Process	The Centre applied to COECSA for accreditation as a Pediatrics & Strabismus Training Centre in writing, via letter or email.
b)   Institution Organization	Briefly describe the institution governance structure? The institution sponsors residency programs in ophthalmology? There is coordination of the fellowship and residency programs, so that both benefit? The fellowship and residency programs are affiliated to other institutions? The institution has the capacity – and appropriate infrastructure – for high quality, diverse exposure to complex pediatric ophthalmology and strabismus cases and their management? Educational activities, including didactic lectures and grand rounds, are available. The institution shall support fellows to participate in research activities, including presentations at meetings, which are part of the pediatric ophthalmology and strabismus fellowship program? The institution has adequate clinical volume? (Specify annual number of patients) There is confirmation of support from the chairman and/or program director of the parent institution. The institution has available work place policies (itemize).
c)     Staff	Fellowship Program Director o   Possess appropriate educational qualifications, including certification in ophthalmology and pediatric/strabismus-fellowship training? o   Has how many years of clinical experience in pediatric ophthalmology and strabismus following his/her fellowship training? o   Has undergone COECSA Train the Trainers’ (TTT) course? o   Is engaged in ongoing basic and/or clinical science research in the area of pediatrics/strabismus, as demonstrated by regular publications in peer-reviewed journals and/or presentation of research material at national and international meetings? o   Has a clinical practice with at least 50% of patients who have pediatric/strabismus related disorders? o   Is licensed to practice medicine in the state or country where the institution that sponsors the program is located? Other Program Personnel The programme will be provided with the additional professional, technical, and clerical personnel needed to support the administrative and educational activities of the program? (specify).
d)   Facilities - Clinic	The outpatient area of the institution has a minimum number of fully equipped examination lanes for each fellow in the clinic? There is ready access to current diagnostic equipment? The following recommended equipment requirements for the outpatient clinic are available? ü  Direct and Indirect ophthalmoscopes ü  Lenses +20D, +90D and +75D. ü  Torch ü  Tonometers; i-care, Sciotz, Tonopen, Perkins or Air puff. ü  Slit lamps- Portable or stand ü  Vision Charts:- Snellen, E, Pictoral ü  Refraction set +Retinoscope ü  Autorefractor ü  Prisms ü  Patches/Occluders ü  Eyedrops/Diagnostics:- Amethocaine, Mydriatics, Atropine and Flourescein strips/drops NOTE: Fellows will be encouraged to have the following as their personal equipment: a.       Ophthalmoscopes; Direct and Indirect b.     Retinoscope c.       Prisms and Occluders d.     Lenses; +20D, +90D and +78D
e)   Operating Facilities	Are the following recommended basic requirements for theatre available? a)     Operating microscope b)     Vitrector- Vitron 2020 c)     IOLs d)     Viscoelastics e)     Knives:- Keratomes, Crescent and MVR f)       Cryo g)     Laser h)     Implants i)       Sutures j)       Lacrimal(probing and syringing) k)     Cataract sets l)       Portable hand held keratometer m)   B-, and A-Scan for biometry
f)     In-patient facilities	Are there inpatient facilities with access to sufficient space and beds for good patient care?
g)     Library and Internet Services	Is there access to a major medical library and facilities for electronic retrieval of information from medical databases?
COMMENTS/ RECOMMENDATIONS BY EVALUATOR:

v.                 Appendix E: Detailed Syllabus

Course Title               :	Vision Development	Code :	P0S1
Credits                        :	0.75
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture/Tutorial	7.5 hours

Learning Aims

o  To acquaint the fellow with the principles of vision development in infancy and childhood

Outline Syllabus

o  Vision development in infancy and childhood and its assessment

Indicative content

o  Normal vision development; revision of neurophysiology of vision

o  Development of normal binocular single vision; stereopsis; depth perception

Evaluation (Theory paper and practical assessments)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Embryology, Anatomy and Physiology of the Eye and Adnexa	Code :	P0S2
Credits                        :	0.75
Status                          :	MUST
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture/Tutotial	7.5hours

Learning Aims

o  This subject provides the fellows with knowledge of the anatomy, functions and physiology of various ocular tissues and their development in newborns, infants, and children. Fellows will develop an understanding of the general physiology of the eye and its relation with selected ocular anomalies. Fellows will acquire knowledge of the neuroanatomy and physiology of the child’s eye necessary for further studies in strabismus and ocular anomalies.

o  Differentiation of germ layers and formation of neural folds; formation of optic vesicle and optic cup; lens formation; development of cornea and anterior chamber, iris and ciliary body, iridocorneal angle, choroids and sclera, retina and retinal vasculature, vitreous, optic nerve, eyelids, nasolacrimal apparatus, extraocular muscles

o  Ocular dysgenesis, malformation complexes involving the eye, brain, and face

Outline Syllabus

o  Anatomy of the eye of the newborn, infant and child

o  Physiology of the eye of the new born, infant and child

o  Neuroanatomy of visual pathways

o  Embryology of the eyeball and adnexa

Indicative content

o  A revision of the anatomy, physiology and embryology of the eye; changes in structure in infancy and childhood

o  A revision of the neuroanatomy of visual pathways; alternate visual pathways

o  Anatomy and motor physiology of extraocular muscles; origin, course, innervation and action of EOM; blood supply; orbital and fascial relationships; axes, planes and arcs; eye movements; supranuclear control systems for eye movements; laws of ocular motility

Evaluation (Theory paper)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Course Title               :	Neonatal Ophthalmology	Code :	P0S3
Credits                        :	1.25
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
LectureTutorial	7.5 hours

Learning Aims

o   This subject provides fellows with essential knowledge in the understanding of neonatal ophthalmology with particular reference to Retinopathy of Prematurity.

Outline Syllabus    

o  Normal and abnormal vasculogenesis

o  Classification

o  Diagnosis and treatment

Indicative content

o  Incidence and natural history; pathogenesis; risk factors; international classification of ROP; clinicopathologic correlation of ROP; regressed ROP; complications

o  Differential diagnosis; examination procedures in the nursery; prophylaxis and therapy; management of advanced ROP

Evaluation (Theory and practical)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Principles of Genetic Eye Disease & Counseling	Code :	P0S4
Credits                        :	0.75
Status                          :	Compulsory
Offering Department:	Clinical Paediatrics

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  This subject provides the fellows with the knowledge of genetics and an understanding into the aetiology and clinical presentation of various inborn errors of metabolism, craniofacial abnormalities and other systemic syndromes. To acquire knowledge and understanding of hereditary patterns in genetic eye disease and genetic counselling

o  Fellows will understand the clinical manifestation and characteristics of ocular abnormalities in childhood metabolic disorders. They will learn to recognise the signs and symptoms, and thus develop skills in the investigation and management effectively. Upon completion of this subject, the fellow will be able to examine, evaluate and manage the cases clinically.

o  To be able to identify the common ophthalmic signs of Inborn Errors of Metaboli

Outline Syllabus

o  Basic concepts of chromosomal disease

o  Single gene mutations

o  Isolated ocular and periocular syndromes

o  Multisystem syndromes

o  Numerical abnormalities

o  Structural abnormalities

o  Sex syndromes

o  Disorders of amino acid metabolism

o  Disorders of lipid metabolism

o  Disorders of glycoprotein degradation

o  Disorders of peroxisomes

o  Disorders of copper metabolism

Indicative content

o  Revision of basic genetics; biochemistry, mitosis, meiosis; nomenclature; types of abnormalities that can occur

o  Examples of single gene mutations and family tree; isolated ocular syndromes with anatomical examples

o  Multisystem syndromes; monogenic syndromes; introduction to metabolic disorders; chromosomal rearrangements

o  Clinical features of trisomy and monosomy syndromes; structural abnormalities and deletion syndromes

o  Sex chromosome syndromes; cytoplasmic and polygenic and multifactorial inheritance

o  Mathematical genetics; distribution of genes in a population; gene frequencies, Bayes theorem; segregation analysis; phenotype markers; gene mapping; linkage

o  Examples and clinical signs and symptoms of disorders of amino acid metabolism, lipid metabolism, glycoprotein degradation, peroxisomes, copper metabolism

o  Investigation and management of childhood metabolic disorders

o  Genetic counselling and prenatal diagnosis; coefficient of inbreeding and recurrence risk; ultrasonography; amniocentesis; chorionic villus sampling; karyotyping

Evaluation (Theory and clinical assessments)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Ophthalmic Manifestations of Systemic Diseases and Craniofacial Syndromes	Code :	P0S5
Credits                        :	0.75
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture	3.75 hours

Learning Aims

o  This subject provides information on the signs and symptoms of syndromes with ophthalmic manifestations, and craniofacial syndromes and malformations. The fellows will be familiarised with the appropriate action to be taken when ocular and systemic disease is recognised and the proper inter-professional referral procedures.

o  To develop skills to recognise the manifestations of these anomalies on the eye and orbit

Outline Syllabus

o   Systemic diseases with ocular manifestations

o  Syndromes with ophthalmic manifestations

o  Craniofacial syndromes and malformations

Indicative Content

o   Examples of systemic diseases with ocular manifestations; Metabolic, vascular, infectiveand neurological disorders

o  Examples and clinical features of syndromes with ophthalmic manifestations; Alcardi, Alport, Alstrom syndromes; CHARGE association; Cockayne syndrome; Cornelia de Lange, Lowe syndromes; Multiple Endocrine Neoplasia; Prader-Willi and Rubenstein-Taybi syndrome

o  Craniofacial syndromes and malformations; terminology; ophthalmic examination; prototypes of craniofacial syndromes; pathogenesis, recurrent risk

Evaluation (Theory and clinical assessments)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Visually Challenged Child	Code :	P0S6
Credits                        :	0.75
Status                          :	MUST
Offering Department:	Low Vision

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  To develop the clinical expertise to perform a low vision assessment and recommend appropriate treatment options.

Outline Syllabus   

o  Epidemiology and causes of low vision

o  Visual acuity measurements in low vision; Log Mar notation;

o  Vision function assessment

o  Optical, non-optical and electronic devices for low vision management

o  Networking with other service providers

Indicative Content

o  Epidemiology and causes of low vision; globally, Pakistan; National programme for low vision

o  Visual acuity measurements in low vision; Log Mar notation; different tests for distance and near, contrast sensitivity tests

o  Vision function assessment; quality of life tools; recognising reading problems (dyslexia)

o  Optical and non-optical devices for low vision management; blind children

o  Networking with other service providers working for the visually impaired; statutory benefits for disabled children; education and vocational training opportunities, rehabilitation options

o  Visit to school for the blind, a low vision assessment clinic and counselling and resource centre

Evaluation (Theory and clinical assessments)

References:

Understanding Low Vision

Randall T Jose

American Foundation for the Blind

Essentials of Low Vision Practice

Richard L Brilliant

Butterworth Heinemann

Subject Title               : Credits                   :0.75	Vision Screening	Code :	P0S7
Status                          :	MUST
Offering Department:	Paediatric Ophthalmology

Learning Aims

o  To acquire clinical skills in the techniques of vision testing in children

o  To acquire clinical skills in the techniques of assessing visual status in preverbal children

Outline Syllabus

o  Vision testing

o  Fixation pattern

o  Preferential viewing

o  Catford drum

Indicative content

o  To learn and use Sheridan Gardiner, Cambridge test and others in testing for visual acuity

o  Use of fixation pattern, preferential viewing and Catford drum and others in assessment of visual status of preverbal children

o  Use of Lea symbols and numbers, and Lea contrast sensitivity tests and others

Evaluation by clinical assessments

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Low Vision	Code :	P0S8
Contract Hours          :	11.25
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Learning Aims

o  To acquire clinical skills in the evaluation of children with low vision and techniques used in its management

Outline Syllabus

o  Assessment of visual acuity – near and far

o  Assessment of visual function

o  Use of optical, non-optical and electronic devices for management of low vision

Indicative content

o  Clinical evaluation of low vision acuity using different tests for near and far

o  Assessment of visual function and contrast sensitivity

o  Use of different types of low vision devices (optical, non-optical and electronic) in the management of children with low vision

Evaluation by clinical assessments

References:

Understanding Low Vision

Randall T Jose

American Foundation for the Blind

Essentials of Low Vision Practice

Richard L Brilliant

Butterworth Heinemann

Course Title               :	Paediatric Ocular Trauma	Code :	P0S9
Credits                        :	0.75
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  To be conversant with the assessment and investigation of paediatric ocular trauma

Outline Syllabus   

o  Injuries to lids and adnexa

o  Orbital trauma

o  Injuries to the globe

o  Child abuse

Indicative Content

o  History, examination, birth and prenatal trauma

o  Injuries to lids and adnexa; ecchymosis, lids laceration

o  Orbital trauma; blow out fracture

o  Injuries to the globe; injuries to conjunctiva and sclera; corneal foreign bodies and abrasions; hyphaema; injuries to the iris, lens; corneo-scleral lacerations/perforations

o  Child abuse; external and anterior segment manifestations; posterior segment manifestations

o  Prevention of ocular trauma

Evaluation (Theory and clinical assessments

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :		Paediatric Oncology		Code:	P0S10
Credits                        :		0.75
Status                          :		Compulsory
Offering Department:		Paediatric Ophthalmology
Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  To familiarise the fellow with the clinical features and presentation of retinoblastoma and the phakomatoses, their investigation and management, including follow-up

o  To acquire knowledge of the clinical features and presentation of orbito-ocular tumours, their investigation and management

Outline Syllabus   

o  Retinoblastoma

o  Rhabdomyosarcoma, Medulloepithelioma

o  Phakomatoses

o  Orbital infections

o  Pseudotumour, mucocele, lymphangioma, hemangioma

o  Tumours of the lids; conjunctiva; uvea

o  Orbital tumours

o  Orbital metastatic disease

Indicative Content

o  Retinoblastoma; clinical signs; pathophysiology; genetic basis; diagnostic approaches; therapeutic approaches; counselling; unilateral, bilateral, trilateral retinoblastoma; differential diagnosis

o  Rhabdomyosarcoma, medulloepithelioma; clinical features, investigation; management

o  Phakomatoses; neurofibromatosis; tuberous sclerosis; Von Hippel-Lindau disease; Sturge Weber Syndrome; Louis Bar syndrome; Wyburn-Mason syndrome

o  Preseptal and orbital cellulitis; orbital infections; hydatid disease

o  Pseudotumour, mucocele, lymphangioma, hemangioma

o  Tumours of the lids; conjunctiva; uvea

o  Orbital tumours; congenital developmental cysts; vascular tumours; neural tumours; lacrimal gland tumours; bony diseases of the orbit

o  Orbital metastatic disease

Evaluation (Theory and clinical assessments)

References:

Diagnosis and Management of Orbital Tumours

Jerry A Shields

WB Saunders Company

Atlas of Intraocular tumours

George E Sanborn, John R Gonder, Jerry A Shields

WB Saunders Company

Ophthalmic Pathology – An Atlas and Textbook

William H Spencer

WB Saunders Company

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Course Title               :	External Ocular Disease	Code :	P0S11
Credits                        :	0.75
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture	3.75 hours

Learning Aims

o  To develop adequate knowledge in recognition of clinical external ocular disease, its management and potential complications

o  To develop skills in microbiology techniques

Outline Syllabus   

o  Conjunctivitis

o  Blepharitis

o  Trachoma

o  Other types of conjunctivitis

Indicative Content

o  Conjunctivitis; neonatal, paediatric conjunctivitis; chemical, bacterial, viral; allergic

o  Blepharitis; anterior, posterior blepharitis;

o  Trachoma; chlamydial infection, pathophysiology, epidemiology, community eye health prevention strategies, treatment, individual, mass, surgery

o  Other types of conjunctivitis; ligneous, associated with systemic disease

o  Evaluation (Theory and clinical assessments)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Course Title               :	Lacrimal Disorders	Code :	P0S12
Credits                        :	0.75
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  To learn the various abnormalities associated with the lacrimal drainage system and the common clinical conditions found in children.

o  To assess lacrimal function in children

Outline Syllabus   

o  Congenital abnormalities of the lacrimal drainage system

o  Acquired disorders of the nasolacrimal system

o  Assessment of lacrimal function

o  Assessment of patency of the nasolacrimal passages

o  Treatment of nasolacrimal duct obstructions

Indicative Content

o  Congenital abnormalities of puncta, canaliculae, dacryocystocele; lacrimal sac, nasolacrimal duct

o  Dacryocystitis

o  Fluorescein dye tests

o  Syringing and probing

o  Lacrimal function tests for dry eye

o  Treatment of nasolacrimal duct obstructions; syringing and probing; DCR; CDCR

Evaluation (Theory and clinical assessments)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Eyelid Disorders	Code :	P0S13
Credits                        :	0.75
Status                          :	Compulsory
Offering Department:	Oculoplastics

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  To provide a systematic and practical background in disorders of the lids and orbit

Outline Syllabus   

o  Congenital entropion and ectropion

o  Epiblepharon and euryblepharon

o  Epicanthus and telecanthus, blepharophimosis

o  Ptosis

o  Coloboma

o  Anophthalmos

o  Cryptophthalmos

Indicative Content

o  Congenital entropion and ectropion; Epiblepharon and euryblepharon;

o  Epicanthus and telecanthus; blepahrophimosis; clinical presentation; surgical management

o  Classification of blepharoptosis

o  Work-up and investigations

o  Surgical management and options

o  Evaluation (Theory and clinical assessments)

References:

Master Techniques in Ophthalmic Surgery

F Hampton Roy

Williams & Willkins

Oculoplastic, Orbital and Reconstructive Surgery Vols 1 and 2

Albert Hornblass

Williams & Wilkins

Ophthalmic Plastic Surgery

Prevention and Management of Complications

Richard K Dortzbach

Raven Press

Colour Atlas of Ophthalmic Surgery – 6 vols

Kenneth W Wright

JB Lippincott Company

Surgery of the Eye – 2 vols

Stephen R Waltman, Richard H Keates, Creig S Hoyt, Bartley R Frueh,

Jonathan Herschler, Denis M Carroll

Churchill Livingstone

Subject Title               :	Cornea Disorders	Code :	P0S14
Credits                        :	0.75
Status                          :	Compulsory
Offering Department:	Clinical Ophthalmology

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  To develop an understanding of corneal and anterior segment disorders and their management.

Outline Syllabus   

o  Dysgenesis of the anterior segment and globe

o  Cornea abnormalities e.g. infections, dystrophies etc

Indicative Content

o  Dysgenesis of the anterior segment and globe; classification; dysgenesis of anterior chamber angle and iris (anterior chamber cleavage syndrome); dysgenesis of the cornea; dysgenesis of the globe

o  Cornea abnormalities; abnormalities of size and shape; cloudy cornea; keratitis, viral, bacterial, fungal, parasitic, others; corneal deposition;

o  Hereditary dystrophies of the cornea; epithelial, stromal, endothelial; degenerations

o  Keratoconjunctivitis sicca

o  Assessments and managements

Evaluation (Theory and clinical assessments)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Uveo-Scleral Disorders	Code :	P0S15
Credits                        :	0.75
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture	3.75 hours

Learning Aims

To acquire knowledge and skills in the management of uveo-scleral disorders.

Outline Syllabus   

o  Paediatric Iris abnormalities

o  Uveitis in children

Indicative Content

o  Congenital anomalies; aniridia, coloboma of iris/uvea

o  Primary iris and uveal tumours

o  Iris colour and membranes

o  Abnormalities in size, shape and location of pupil

o  Classification of uveitis; clinical features; anterior uveitis, posterior uveitis, parsplanitis

o  Episcleritis, scleritis, endophthalmitis

o  Evaluation and management.

Evaluation (Theory and clinical assessments)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Lens Disorders	Code :	P0S16
Credits                        :	2.25
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  This subject provides the fellows with clinical knowledge and understanding of lens disorders.

Outline Syllabus

o   Lens opacities and classification

o  Abnormality of lens transparency

o  Abnormal lens position

o  Abnormal lens shape

Indicative content

o  Paediatric cataracts and classification; aetiology of paediatric cataracts; systemic evaluation; indications for surgery, management (surgical, aphakia, pseudophakia, optical correction/rehabilitation); monocular lenticular problems

o  Subluxation/luxation of lens; ocular causes; systemic syndromes; management of subluxated/luxated lens; lens coloboma

Evaluation (Theory and clinical assessments)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Paediatric Glaucoma	Code :	P0S17
Credits                        :	1.25
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture	3.75hours

Learning Aims

o  To develop an understanding into the aetiology, clinical presentation, assessments and management of paediatric glaucoma

Outline Syllabus   

o  Anatomical and physiological basis for paediatric glaucoma

o  Classification paediatric glaucoma

o  Types and management

Indicative Content

o  Pathophysiology of paediatric glaucoma

o  Classification

o  Primary infantile glaucoma; juvenile glaucoma; Secondary glaucoma, angle anomaly; other secondary glaucomas

o  To learn and use different equipment for measurement of IOP and gonioscopy

o  Diagnosis, investigation, management, follow-up protocol, trabeculotomy/trabeculectomy with antimetabolites and goniotomy

Evaluation (Theory and clinical assessments)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Retina And Vitreous Disorders	Code :	P0S18
Credits                        :	1.5
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  To acquire knowledge of paediatric vitreo-retinal disorders and their management

Outline Syllabus   

o  Hereditary disorders of RPE, Bruch’s membrane and choriocapillaris

o  Retinitis pigmentosa and associated disorders

o  Disorders of vitreous and vitreoretinal interface

o  Retinal vascular disorders

o  Infectious, inflammatory and toxic diseases of the retina and vitreous

o  Pathological Myopia

o  Congenital abnormalities of the optic disc

o  Patterns of retinal disease in children

Indicative Content

o  Hereditary disorders of RPE, Bruch’s membrane and choriocapillaris; dystrophies, choroidopathies

o  Retinitis pigmentosa and associated disorders; RP and other photoreceptor dystrophies

o  Disorders of vitreous and vitreoretinal interface; vitreoretinopathies

o  Retinal vascular disorders

o  Pathological Myopia

o  Congenital abnormalities of the optic disc

o  Patterns of retinal disease in children; characteristic fundus patterns; systemic disorders associated with retinal abnormalities; treatable systemic disorders with associated retinopathy

Evaluation (Theory and clinical assessments)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Neuro-Ophthalmology	Code :	P0S19
Credits                        :	0.75
Status                          :	Compulsory
Offering Department:	Paediatric Neurology

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  To develop an understanding in the aetiology, clinical presentation and management of various neuro-ophthalmic disorders in childhood

o  A blind infant – aetiology and approach to management

Outline Syllabus   

o  Paediatric neuro-ophthalmic examination

o  Ocular motility disorders

o  Congenital optic nerve abnormalities

o  Cerebral visual impairment

o  Apparently blind infant

o  Brain lesions with ophthalmologic manifestations

o  Childhood nystagmus

o  Neurodegenerative conditions of ophthalmic importance

o  Neuro-cranial defects with neuro-ophthalmic significance

o  Management of common paediatric neuro-ophthalmology problems

Indicative Content

o  Paediatric neuro-ophthalmic examination; visual acuity, pupillary examination, ocular motility, confrontational visual fields, colour vision, fundoscopic examination, general neurologic examination

o  Ocular motility disorders; types of eye movements; supranuclear eye movement disorders; ocular motor apraxia; dorsal midbrain syndrome; transient vertical gaze disturbances; spasm of the near reflex; internuclear ophthalmoplegia; myasthenia gravis

o  Congenital optic nerve abnormalities; cortical visual impairment, causes;

o  Brain lesions with ophthalmologic manifestations; congenital abnormalities; hydrocephalus; perinatal injuries; infection; tumours

o  Childhood nystagmus; neurophysiology of nystagmus; neonatal nystagmus; acquired nystagmus;

o  Neurodegenerative conditions of ophthalmic importance; lysosomal storage diseases and leucodystrophy’s; Peroxisomal diseases; mitochondrial diseases; disorders of myelin production; disorders of unknown aetiology

o  Neuro-cranial defects with neuro-ophthalmic significance; progressive hemifacial atrophy; cervico-occipital proximity diseases

o  Management of common paediatric neuro-ophthalmology problems; functional visual loss; headaches; swollen optic disc; anisocoria; neonatal blindness

o  The blind infant

Evaluation (Theory and clinical assessments)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Electrophysiology	Code :	P0S20
Credits                        :	0.75	Level :	5
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  This subject provides information on the basis of electrophysiology and its use in electrodiagnostics.

o  To acquire clinical skills in the techniques of electrophysiology in various ocular diseases

Outline Syllabus

o  Basic concepts of electrodiagnostic tests

o  Electroretinography

o  Electro-Oculography

o  Visual Evoked Response

o  Electromyography

o  Electronystagmography

o  Clinical uses

Indicative Content

o  Principles of electrophysiology and electrodiagnostic testing

o  ERG, EOG, VER, EMG, ENG

o  Clinical uses of electrodiagnostic tests; infants with nystagmus and poor vision from birth; children with overt but nondiagnostic macular lesions; children in whom a generalised retinal degeneration is suspected; children with onset of decreased vision of unknown cause

Evaluation (Theory and case scenarios)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Imaging in Paediatric Ophthalmology	Code :	P0S21
Credits                        :	0.75
Status                          :	Compulsory
Offering Department:	Paediatric Radiology

Teaching Pattern

Learning Aims

o  To acquire more advanced knowledge and skills on the different imaging techniques, their indications and interpretations.

Outline Syllabus   

o  Plain X-ray

o  Ultrasonography

o  CT-Scan

o  MRI

Indicative Content

o  Plain X-ray; views and interpretation, skull, chest, long bones, lumbar and hip; fractures, tumours

o  Ultrasonography; A and B scans; lids and orbit, AP length, globe; localisation of foreign bodies, retinal detachment, blood in vitreous, ocular tumours

o  CT-Scan; skull and orbital views, with and without contrast, tumours

o  MRI; skull and brain views, orbit; tumours

Evaluation (Theory and clinical assessments)

References:

Modern Neuroradiology – Radiology of the Eye and Orbit

Thomas H Newton, Larissa T Bilaniuk

Raven Press

Noninvasive Diagnostic Techniques in Ophthalmology

Barry R Masters

Springer-Verlag

Orbital Disease – Imaging and Analysis

Daniel S Casper, T Lionda Chi, Stephen L Trokel

Thieme

Magnetic Resonance Imaging of the Paediatric Brain

An Anatomical Analysis

G Salamon, C Raynaud, J Regis, C Rumeau

Raven Press

Fluorescein Angiography – Textbook and Atlas

Gisbert Richard

Thieme

Subject Title               :	Ethics in Paediatric Ophthalmology	Code :	P0S22
Credits                        :	0.55
Status                          :	Compulsory
Offering Department:	Paediatric Radiology

Teaching Pattern

Learning Aims

o  To acquire more advanced knowledge on ethical issues of relevance to the practice of paediatric Ophthalmology.

Subject Title               :	Anatomy and Physiology of EOM	Code :	P0S23
Credits                        :	0.50
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  This subject provides the fellows with knowledge of the anatomy, functions and physiology of various ocular tissues and their development in newborns, infants, and children. Fellows will develop an understanding of the general physiology of the eye and its relation with selected ocular anomalies. Fellows will acquire knowledge of the neuroanatomy and physiology of the child’s eye necessary for further studies in strabismus and ocular anomalies.

Outline Syllabus

o  Anatomy of the eye of the newborn, infant and child

o  Physiology of the eye of the new born, infant and child

o  Neuroanatomy of visual pathways

Indicative content

o  A revision of the anatomy and physiology of the eye of the new born; changes in structure in infancy and childhood

o  A revision of the neuroanatomy of visual pathways; alternate visual pathways

o  Anatomy and motor physiology of extraocular muscles; origin, course, innervation and action of EOM; blood supply; orbital and fascial relationships; axes, planes and arcs; eye movements; supranuclear control systems for eye movements; laws of ocular motility

Evaluation (Theory)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Sensory Adaptation	Code :	P0S24
Credits                        :	0.50
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  To enable fellows understand sensory adaptation in children and its relationship to clinical work

o  To acquire clinical skills in the techniques of assessing sensory status of binocular single vision

Indicative content

o  Abnormalities of BSV; suppression; anomalous retinal correspondence; confusion; diplopia; monocular deprivation; monofixation

o  Tests for suppression, BSV, ARC and stereoacuity

o  Use of Bagolini glasses, Lange stereo cards, Titmus tests and others in assessment for BSV and sensory adaptation

Evaluation (Theory and clinical assessments)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Amblyopia	Code :	P0S25
Credits                        :	0.50
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  This subject provides a basic understanding of amblyopia.

Outline Syllabus

o  Definition and types

o  Classification

o  Diagnosis and treatment

Indicative content

o  Nature of amblyopic vision; classification of functional amblyopia; diagnosis of amblyopia; examination of the amblyopic child; prescribing spectacles in amblyopia

o  Amblyopia therapy; patient selection and prognostic factors; special forms of amblyopia

Evaluation (Theory and clinical assessments)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Clinical Refraction	Code :	P0S26
Contract Hours          :	11.25
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Learning Aims

o  To acquire clinical skills in the techniques of refraction

Outline Syllabus

o  Retinoscopy, hand held keratometry, hand held autorefractor

Indicative content

o  Use of retinoscopy, hand held keratometry and hand held autorefractor for refraction

Evaluation by clinical assessments

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :		Esodeviations and Exodeviations		Code :	P0S27
Credits                        :		0.75
Status                          :		Compulsory
Offering Department:		Paediatric Ophthalmology
Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  This subject prepares the fellows to develop the theoretical background to Eso AND Exo-deviations

Outline Syllabus

o  Evaluation of a strabismic child

o  Esodeviations – classification, common types

o  Exodeviations – classification

Indicative content

o  Evaluation; history, examination, visual acuity, ocular motility, ductions, versions, vergences; measuring ocular deviation, light reflex tests, cover tests, prism cover tests

o  Measuring the AC/A ratio

o  Classification of esodeviations; esophoria; congenital esotropia; accommodative esotropia, non-accommodative esotropia; esotropia and nystagmus; pseudo esotropia, microtropia; comitant and incomitant deviations

o  Exophoria; intermittent exotropia; exotropia; convergence insufficiency; divergence excess; sensory exotropia; comitant and incomitant deviations

o  Management

Evaluation (MCQ), clinical assessments

References:

Binocular Vision and Management of Strabismus

Theory and Management of Strabismus

GK Von Noorden

CV Mosby

Clinical Orthoptics

Fiona Rowe

Blackwell Science

Diagnosis and Management of Ocular Motility Disorders

Joyce Mein, Roger Trimble

Blackwell Science Publications

Management of Strabismus and Amblyopia – A Practical Guide

John A Pratt-Johnson

Geraldine Tillson

Thieme

Clinical Management of Strabismus

Elizabeth E Caloroso, Michael W Rouse

Butterworth-Heinemann

Subject Title               :	Vertical Squints and Incomitant Deviations	Code :	P0S28
Credits                        :	0.50
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  This subject prepares the fellows to develop the theoretical background to vertical squints, and will cover the pathophysiology and clinical presentation of cranial nerve palsies as associated with ocular motility and their management

Outline Syllabus

o  Oblique overaction and A and V patterns

o  Vertical squints

o  Diagnosis of incomitant strabismus

o  Third nerve palsy

o  Fourth nerve palsy

o  Sixth nerve palsy

o  Strabismus associated with orbital wall fracture

o  Slipped muscle

Indicative Content

o  Classification; pseudo; dissociated vertical deviations; comitant and incomitant deviations; double elevator palsy; isolated inferior oblique paresis; syndromes; dissociated strabismus complex; 4^th nerve palsy

o  Torticollis; Abnormal head posture (AHP); 3 step head tilt test; (differentiation between Bielschowsky’s and Marshall Parks)

o   Tests for identifying restriction and paresis

o  Clinical diagnosis of incomitant strabismus

o  Signs and symptoms of 3^rd, 4^th and 6^th nerve palsies; investigation; use of Lees screen, ocular motility; management, differential diagnosis

o  Forced duction test, Forced Generation test

Evaluation (Theory and clinical assessments)

References:

Binocular Vision and Management of Strabismus

Theory and Management of Strabismus

GK Von Noorden

CV Mosby

Clinical Orthoptics

Fiona Rowe

Blackwell Science

Diagnosis and Management of Ocular Motility Disorders

Joyce Mein, Roger Trimble

Blackwell Science Publications

Management of Strabismus and Amblyopia – A Practical Guide

John A Pratt-Johnson

Geraldine Tillson

Thieme

Clinical Management of Strabismus

Elizabeth E Caloroso, Michael W Rouse

Butterworth-Heinemann

Subject Title               :	Ophthalmoplegic and Restrictive Syndromes	Code :	P0S29
Credits                        :	0.50
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  This subject aims to provide fellows with the theoretical and practical background necessary to diagnose and manage appropriately various ophthalmoplegic and restrictive syndromes.

Outline Syllabus  

o  Duane retraction syndrome

o  Mobius syndrome

o  Brown syndrome

o  General fibrosis syndrome

o  Grave’s ophthalmopathy

Indicative content

o  Clinical features and essentials of diagnosis of Duane retraction syndrome, Mobius syndrome, Brown syndrome, General fibrosis syndrome, Grave’s ophthalmopathy

o  Investigation and management

Evaluation (MCQ) and clinical assessments

References:

Binocular Vision and Management of Strabismus

Theory and Management of Strabismus

GK Von Noorden

CV Mosby

Clinical Orthoptics

Fiona Rowe

Blackwell Science

Diagnosis and Management of Ocular Motility Disorders

Joyce Mein, Roger Trimble

Blackwell Science Publications

Management of Strabismus and Amblyopia – A Practical Guide

John A Pratt-Johnson

Geraldine Tillson

Thieme

Clinical Management of Strabismus

Elizabeth E Caloroso, Michael W Rouse

Butterworth-Heinemann

Subject Title               :	Nystagmus	Code :	P0S30
Contract Hours          :	0.75
Status                          :	Compulsory
Offering Department:	Paediatric Ophthalmology

Learning Aims

o  Aetiolgy and types of Nysatamus (Classification)

o  Assessment of nystagmus

Outline Syllabus

o  Assessment of ocular nystagmus by different methods

Indicative content

o  To learn the use of different equipment in assessing nystagmus

o  Management of Nystagmus

Evaluation (Theory and clinical assessments)

References:

Paediatric Ophthalmology and Strabismus – Basic and Clinical Science Course, American Academy of Ophthalmology

Textbook of Ophthalmology - Strabismus and Paediatric Ophthalmology,

Gary R Diamond, Howard M Eggers

Mosby

Paediatric Ophthalmology and Strabismus

Kenneth W Wright

Mosby

Harley’s Paediatric Ophthalmology

Leonard B Nelson

WB Saunders Company

Paediatric Ophthalmology

David Taylor

Blackwell Science

Subject Title               :	Applied Statistics and Research Methodology RESEARCH PROJECT	Code :	P0S31
Credits                        :	2.5
Status                          :	Compulsory
Offering Department:	Community Ophthalmology

Teaching Pattern
Lecture	7.5 hours

Learning Aims

o  To make the student appreciate the ethical issues that may be encountered in research.

o  To acquire the skills required for location and critical evaluation of relevant journal papers.

o  To acquire knowledge of the principles involved in the conception, design, conduct and completion of research projects.

o  To learn the fundamentals of probability and the statistical methods needed for the analysis of quantitative data.

Note: The fellows will work through a research project, from problem identification to the production of a research report.

Outline Syllabus

o  Research ethics

o  Reviewing and criticising the literature

o  Structuring a literature review and a research report

o  Experimental design

o  Generating hypotheses

o  Describing and displaying quantitative data

o  Choosing and using appropriate statistical tools

o  Interpreting and reporting the results of statistical tests

o  How to write a report

o  Use of computer and EPI-INFO

Evaluation (Theory and assessment of final research project and manuscript)

References:

Intuitive Biostatistics

Motulsky H

Oxford University Press

Introduction to research in the Health Sciences

Polgar S and Thomas SA

How to plan and write a scientific paper: I. Preparation

Farris RL

CLAO Journal, 1998, 14 (4): 223-6

II. Writing.

CLAO Journal, 1989, 15 (1): 88-90

SURGERY

1. Surgical training is required in this surgical subspecialty. [M]
2. The fellow must perform a sufficient number of procedures to achieve competence. Recommended numbers of procedures are presented under “Surgical Requirements,” but it is recognized that individual programs utilizing these guidelines may need to vary these minimum numbers based on local needs and resources.Surgical competency should be assessed using a measurement such as the ICO-Ophthalmology Surgical Competency Assessment Rubric (OSCAR): icoph.org/ico-oscar.
3. Fellowships can focus more on surgery in strabismus or pediatric ophthalmology.
4. The fellow must participate in the pre- and postoperative care of the majority of surgical cases in which he/she serves as the primary surgeon. [M]

Appendix F: Resources and Materials

A.    Books

1. Wright KW. Pediatric Ophthalmology and Strabismus. 3rd ed. Oxford; 2012.
2. Lambert S, Lyons C. Taylor and Hoyt's Pediatric Ophthalmology and Strabismus.5th ed.Elsevier; 2016.
3. Raab EL. Basic and Clinical Science Course 2010-2011 Section 6.Pediatric Ophthalmology and Strabismus. American Academy of Ophthalmology. Revised.
4. Prieto-Diaz J, Souza-Dias C.Strabismus.4th edition. Butterworth-Heinemann; 2000.
5. Wright KW.Color Atlas of Strabismus Surgery: Strategies and Techniques. 3rd ed. Springer; 2007.
6. TraboulsiE.Genetic Diseases of the Eye (Oxford Monographs on Medical Genetics).2nd ed. Oxford University Press; 2011.
7. Ferris J, Davies P. Strabismus Surgery–Strabismus Techniques in Ophthalmology. 1st ed. Saunders Ltd; 2007. (DVD illustrates each technique)
8. Buckley EG, Plager DA, Repka MX, Wilson ME. Plager DA, eds. Strabismus Surgery:Basic and Advanced Strategies. 1st ed. Oxford University Press; 2004

B.    Journals

1. Journal of the American Association of Pediatric Ophthalmology. www.jaapos.org
2. Journal of Pediatric Ophthalmology & Strabismus. www.slackjournals.com/jpos
3. Ophthalmic Genetics. http://www.tandfonline.com/loi/iopg20

C.         Online resources

1. AO One Network. http://one.aao.org
2. ICO Ethical Guidelines for Ophthalmologists: Ethical Principles and Professional Standards. http://www.icoph.org/downloads/icoethicalcode.pdf
3. ICO-Ophthalmology Surgical Competency Assessment Rubric (OSCAR), including strabismus surgery rubric.http://www.icoph.org/resources/230/Surgical-Assessment-Tool-ICO-OSCAR-in-English-Chinese-Portuguese-Russian-Spanish-Vietnamese-and-French.html
4. OMIM Genetic Database.http://www.ncbi.nlm.nih.gov/omim
5. Orphanet.www.orpha.net/
6. Rosenbaum AL, Santiago AP. Clinical Strabismus Management: Principles and Surgical Techniques. 1st ed. W. B. Saunders Company; 1999. Out of print. Available free online:https://books.google.com/books?isbn=0721676731
7. von Noorden GK, Campos EC. Binocular Vision and Ocular Motility. 6th ed.
8. Mosby; 2002.Out of print.PDF available free online:http://www.cybersight.org/.../3285_5.85MB_Binocular_Vision_and_Ocular_Motility.pdf
9. OrbisCybersight. https://consult.cybersight.org/web/main
10. Simulated Ocular Surgery. http://simulatedocularsurgery.com/simulation/strabismus/http://simulatedocularsurgery.com/simulation/strabism